ISSN0535-1405

No. 512

July 31, 2022
Published by International Medical Society of Japan,Chairman, Board of Directors: Kenichi Ishibashi, MD, PhD
Editors: K. Ito, MD, PhD, T. Kondo, MD, PhD,K. Ichihashi, MD, PhD, T. Murakami, PhD, R.Nagai, MD, PhD,
I. Taniguchi, MD, PhD, and T. Yamazaki, MD, PhD
3F MK Sangenjaya Building, 1-15-3 Kamiuma, Setagaya-ku,Tokyo154-0011,Japan.
TEL 03(5486)0601 FAX 03(5486)0599 E-mail: imsj@imsj.or.jp https://www.imsj.or.jp/

The 454th International Symposium on Therapy
The 454th International Symposium on Therapy
was held by the Zoom Webinar on May 19, 2022.
Dr. Ikuo Taniguchi, Director of the International
Medical Society of Japan (IMSJ), presided over themeeting.

The publicization of public exams for
medical students (CBT and OSCE)
Introductory Message from the Chair
Ikuo Taniguchi, MD, PhD
Director, IMSJ
We have taken up the theme of medical education,
which has not been covered very often in the past.
In recent years, medical education in Japan has
undergone significant changes with international
accreditation in mind. In order to raise the levelof physician training, clinical clerkships in which
students actually perform medical procedures
have been introduced. In addition, since 2005,
student have taking the CBT(Computer BasedTest) and the OSCE(Object Structured ClinicalExamination) prior to clinical clerkship to be
objectively evaluated and conducting clinicaltraining as Student Doctors (certified by Associationof Japan Medical Colleges-AJMC). In 2020, theMedical Ethics Council's Subcommittee on Medical
Practice reported that the OSCE would be madeofficially nationwide by 2025, and that the OSCE
would also be conducted after completionof practical training to qualify for the nationalexamination. Takako Shimizu MD,PhD, a memberof the Medical Ethics Council and a directorof Common Achievement Tests Organization
talked to us, and Vice President Nobuhiko Saito

MD.PhD, who has been involved with this Common
Achievement Tests Organization for many years,
gave a concrete talk about the current statusof the Common Achievement Tests and also
explained about the future publicization. I believethat the actual implementation will be very difficult
due to the differences in viewing things differently
among universities and the problems with theauthorities in charge, but it is a big turning point
in medical education, and we pray for further
success toward the operation in 2025.

LectureⅠ
Publicization of pre-clinical OSCE
from the viewpoint of consistency ofphysician training
Takako Shimizu MD,PhD
Adviser
Seirei Social Welfare Community
The post-graduate clinical training system forphysicians, which has been mandatory since2004, specifies the goals to be achieved at theend of clinical training. Medical schools havealso established a model core to be achieved
upon graduation, as described below. Both arereviewed periodically, but in February 2017, during
the course of the last revision, a joint meeting washeld to discuss both, and some of the goals wereunified. From the perspective of consistency in thephysician training process, this was a milestone.
Medical education in Japan has often focusedon knowledge-based education in the classroom,
clinical training was mainly observation-based,

Page 8International Medical Newsand practicing medicine for the first time after
graduation. Although problems inherent with thisknowledge-based curriculum were pointed out
early on, specific studies on how to deal with theseissues only began at the end of the 20th century.
An "Advisory Committee on Medicine and Medical
Care in the 21st Century," which was organizedby the former Ministry of Education from 1996 to1999, recommended the "creation of a model
core curriculum" and the "active introductionof participatory clinical clerkships". In the fourthreport, it was also pointed out that "a certain
standard should be ensured nationwide for theevaluation of the ability and aptitude of students
starting clinical training" and "consideration should
be given to creating a common evaluation
system for accreditation of progression". These
reports were the starting point for the creation ofthe model core curriculum for medical schools,
which was subsequently introduced, and for theimplementation of shared examinations.
In March 2001, the "Committee for Researchand Development of Educational Programs inMedicine" proposed a model core curriculum. The
Model Core Curriculum systematically presents as a"model" the "core" areas that should be commonlyaddressed by all universities. Each university
formulates its curriculum with reference to theModel Core Curriculum for approximately 2/3 ofits study hours, while the remaining 1/3 is unique toeach university.
In order to improve the existing clinical training,
medical students must be able to participate
as members of the medical team rather thanas strictly observers. For this to be realized it wasnecessary to prevent the illegality of performing
medical treatment that only doctors are allowed
to perform. In the final report issued in 1991
by the former Ministry of Health and Welfare's
Clinical Practice Review Committee (chaired by
Tadashi Maekawa), the following conditions wereproposed as conditions under which medical
practice by medical students could be interpreted
as not being illegal in order to prevent "medicalstudents' participation in actual medical treatment
and medical practice from violating the MedicalPractitioners Act".
(1) Limited to certain non-invasive procedures.
(2) Under the careful guidance and supervision ofa supervising physician.
(3) Evaluation of medical students is conducted inadvance.
(4) Obtain consent from the patient.
In response to (3) above, the CBT (ComputerBased Testing) and OSCE (Objective Structured

Clinical Examination) were established in 2003 as
preclinical training qualification examinations for
medical students and are now administered by
the Common Achievement Tests Organization(CATO). Regarding the medical practices that
medical students are allowed to perform, the final
report of the Clinical Practice Review Committee,
as mentioned above, includes examples of basic
medical practices that are acceptable undercertain conditions ("Maekawa Report"). The"Monden Report" was issued in 2018.
In May 2021, a partial revision of the MedicalPractitioners Act was promulgated, allowing
medical students who have passed the commonuse examination (CBT and pre- clinical clerkshipOSCE) to practice medicine, excluding the writingof orders or prescriptions, under the guidance andsupervision of a physician during clinical practicefrom April 1, 2023. After April 1, 2025, passing thecommon use examination will be a requirement
for eligibility to sit for the national medical
examination.
This new legal framework will allow for comprehensive
and participatory clinical training which will ensure
consistency from pre-graduation to residency.
Working closely with an experienced medical
team should foster a culture of professionalism andtrain physicians who can truly contribute to thecommunity in which they work and society as awhole.

LectureⅡ
The Common Achievement Tests for
Medical Students
Nobuhiko Saito MD.PhD
Vice President
Common Achievement Tests Organization
Introduction
In medical schools and medical colleges, students
in their senior year are required to participate inclinical training at university hospitals and regional
medical institutions. Clinical clerkship is a training
program in which medical students are required toparticipate in a clinical trial in a university hospitalor a local medical institution. It is an on-the-job
training in which students are involved in actualmedical practice as a member of the medical
team under the guidance and supervision of asupervising physician.
However, it is against the Medical Practitioners Law
for medical students who are not yet physicians
to engage in actual medical practice. In orderPage 9to prevent this illegality, students are required topass the Common Achievement Test (CAT) which
consists of two strict examinations, Computer Based
Testing (CBT) and the Objective Structured ClinicalExamination (OSCE).
The Common Achievement Test Organization(CATO) was established 17 years ago with theparticipation of all medical schools to administer
the CAT. Questions created by each university arepooled and shared among the universities.
Presently, each university is responsible forevaluating the results of these examinations,but in 2021 the Medical Practitioners Law wasrevised, and from 2023 both examinations will
become public examinations, with uniform passing
standards applied throughout the country.

CBT
CBT is an examination that measures theacquisition of knowledge. 320 MCQ questions
are divided into six blocks on a PC screen. The
sixth block, in particular, consists of a series of fourquestions on a case. The first question asks about
the medical history, the second question asks
about the physical examination findings, and thethird question asks about the examination results,
each in a five-choice format, while the fourthquestion asks about the basic medical knowledgeof the case.
The questions are randomly selected from a pool ofquestions whose difficulty and discriminatory power
are known through prior trials, based on a test
theory called item response theory (IRT). This system
makes it possible to conduct the same evaluationeven if the test is administered on different days atdifferent universities and to have different students
take the test.

OSCE
Before starting a clinical clerkship, the candidate
must have acquired sufficient skills in patientcare, information gathering, and examination
procedures. The OSCE, a simulation test, is used toevaluate these skills.
The following is an example of an OSCE currently
being conducted by CATO.
Several small rooms are prepared, and in eachroom there is an evaluator who has undergone
evaluation training in advance. When theexaminee enters the first small room, he or she isasked to "conduct a medical interview," and amock patient is waiting outside. The candidate
then invites the mock patient in and asks about theInternational Medical News

reason for the visit and the history of the patient.
The mock patient answers according to thescenario taught in advance. When time is up, theexaminee moves to the next room, where anothersimulated patient (or a simulator, depending on
the task) is present, and is asked to "perform achest examination," so the examinee examines thesimulated patient's chest. When they move to thenext room again, they are asked to "examine theabdomen," and another simulator is present. In thisway, the examinees perform the tasks presented
in each small room, such as head and neckexamination, neurological examination, infection
control, and first aid, on the simulated patients andsimulators. The evaluator in each room observes
the students' performance of the tasks and enters
it in the evaluation form. When the students havevisited all the rooms, they are evaluated as towhether they have acquired all the necessary
skills at the beginning of their clinical practice.
Internationally, it is recommended that theappropriate number of examination tasks (numberof small rooms) be 12 or more, but considering thecurrent situation in medical schools in Japan, webelieve that at least 10 tasks should be conducted.
Tabulation of results and pass/fail decisions
The results of both examinations are tabulated
and statistically processed by CATO. The minimum
standardized passing scores for the CBT and OSCE
are determined in advance by the Bookmark
method and the modified Angoff method,respectively, and the draft pass/fail decisions
are made based on the results. The details of thesubsequent review by the MHLW have not yet
been determined.
Pre-Clinical Examination for COVID-19 pandemic
However, there are still some unresolved issues,
such as measures to increase the burden oneach university to administer the examinationand to train standardized mock patients, and theschedule may be changed depending on theSARS-CoV-2 situation. In FY2023, the CBT may be
implemented as originally planned, but transitional
measures may be necessary for the OSCE, such as
starting with 8 tasks and increasing to 10 tasks inFY2025.
OSCE after clinical practiceThe current National Medical Examination for
Medical Examiners (NMEED) can evaluate the levelof knowledge acquired at the time of graduationfrom medical school, but fails to evaluate clinicalskill and attitude.

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International Medical News

It would be best if evaluators could be dispatched
to practice sites to conduct workplace-based
assessments, but this is not possible on a nationwide
scale. Therefore, in order to measure the degree towhich clinical skills and techniques were acquired
during the clinical clerkship, we have been
conducting a series of trials since last year using
a scenario-based OSCE assignment as a postclinical training OSCE. These are continually being
evaluated and refined and we are hoping to makethem official in 2025.

Discourse
Introduction of the speaker of discourse
Ikuo Taniguchi, MD, PhD
Director, IMSJ
Kazuo Futagawa dedicated to the labor andwelfare field ever since he joined the Ministryof Health, Labour and Welfare and retired as
Administrative Vice Minister of the MHLW in 2017,
but his talk conveyed his passion for the MHLW
even today. He has always been familiar with thehealthcare field and is also well versed in the fieldsite. Japan has become an elderly society, and theneeds for medical and nursing care are increasing,and social security costs are steadily increasing.
However, what is important is to improve the qualityof social security, and to encourage the elderly
to play an active role. In order to do so, he said
that it is necessary to focus on motivation to workand preventive medicine, increase productivity byusing ICT, and secure human resources. Now that
he is in a position where he can express his opinions
relatively freely, we are sure that his future opinions
will attract a lot of attention. Thank you very muchfor the lecture.

Discourse: Current Status and Issuesof the Ministry of Health, Labour andWelfare and Social Security in Japan
Kazuo Futagawa
Member of the Board, Toray Industries, Inc.
Senior researcher, Health care policy,
Industrial investigation laboratory,
Japan Healthcare General Institute, Inc.
I. Japan's Ministry of Health, Labour and Welfare(MHLW) is in charge of the social security sector
within the government. The expenditure budget forthe social security sector accounts for about onethird of the total government budget and, in effect,a majority of general expenditures, making it thelargest expenditure sector in the government. Inaddition, looking at the growth of the budget overthe past 20 years or so, social security has morethan doubled, a more prominent growth than otherspending areas. The fact that budget expenditures
are high is a clear indication that the workload isalso high. In terms of the number of answers givenby ministers and others in the Diet, the Ministry ofHealth, Labor, and Welfare (MHLW) stands out fromother ministries in terms of the number of answers
given. This is not because of the COVID-19, but is atrend that has continued since before the disaster.
The Ministry of Health, Labor, and Welfare (MHLW) isan organization that often faces criticism in various
areas, including its response to the new coronavirus.
In this way, the Ministry of Health, Labor and Welfare
has a large amount of work, but the number of staff
members of the Ministry proper is small, and theburden on the staff is extremely large.
Some of the Liberal Democratic Party (LDP)
proposed a split in the Ministry of Health, Labourand Welfare (MHLW) or two ministers in the MHLW
some time ago. Incidentally, looking at othercountries, the number of countries that have asingle organization in charge of social security
policy and labor policy is basically nowhere to befound. How the organization should be is a difficult
issue, but ensuring that it can accurately meet theneeds of the public is considered an important task
for the future.
II This section discusses issues from the policy
perspective of the social security system. Themagnitude of needs for social security benefits suchas pensions, medical care, and nursing care can beeasily understood by looking at population trends.
In particular, medical and nursing care needs areclosely related to the volume of the population
aged 75 and over. Although the total population
is expected to decline significantly, the populationof the 75+ age group is expected to increasesignificantly until 2025, reaching around 2.2 million,
and then will not decline until around 2065. In otherwords, this means that the population will continue
to increase by 40% compared to 16.3 million in 2015,
and by 20% compared to 2020. In addition, the later
the population is aged 75 and over, the greater theweight of the older age groups, such as those aged
80 and over and 85 and over. This suggests that theneed for nursing care will increase significantly morethan the need for medical care.
The future projection of social security benefit costs(2040) shows a slight decrease in pensions as apercentage of GDP, but a large increase in medicalcare and nursing care. Comparing 2018 and 2040,

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medical care will increase by approximately 20%,from 7.0% to 8.4-8.7%, and nursing care from 1.9%
to 3.3%, an increase of 70-80%. In order to coverthese medical and nursing care needs, insurance
premiums and taxes could be increased, but thisis not considered easy in the real political process.
In order to maintain the universal health insurance
and nursing care insurance systems in the future,
it is considered essential to review the contents ofbenefits along with health promotion and nursing
care prevention.
In addition, in order to meet the future needs ofmedical and nursing care services, it will be evenmore important to secure the human resources,
including medical and nursing care staff, who will
be involved in providing medical and nursing careservices. Since the total population is declining, it
is clear that it will not be possible to simply bring in
new young people into the medical and nursing
care fields as has been done in the past. Active
participation of elderly people who are willing towork (In Japan, there are more elderly people whoare willing to work than in Western countries, so
there are great expectations. Extending healthy
life expectancy is also important in this regard.),active participation of women in the child-rearing
generation (The so-called M-shaped curve isimproving, but there is still room for improvement.),
and the utilization of foreign workers throughthe EPA and technical training schemes. What iseven more important are reform efforts aimed atimproving the productivity of medical and nursing
care services through the use of machines, IT, andother means that are not bound by conventional
thinking. The following is an example from thenursing care sector of Zenkoukai in Ota Ward,Tokyo, which is considered to be an excellent
example of such efforts.

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